title: Endoscopic transluminal pancreatic necrosectomy using a self-expanding metal stent and high-flow water-jet system.
abstract: Walled-off pancreatic necrosis and a pancreatic abscess are the most severe complications of acute pancreatitis. Surgery in such critically ill patients is often associated with significant morbidity and mortality within the first few weeks after the onset of symptoms. Minimal invasive approaches with high success and low mortality rates are therefore of considerable interest. Endoscopic therapy has the potential to offer safe and effective alternative treatment. We report here on 3 consecutive patients with infected walled-off pancreatic necrosis and 1 patient with a pancreatic abscess who underwent direct endoscopic necrosectomy 19-21 d after the onset of acute pancreatitis. The infected pancreatic necrosis or abscess was punctured transluminally with a cystostome and, after balloon dilatation, a non-covered self-expanding biliary metal stent was placed into the necrotic cavity. Following stent deployment, a nasobiliary pigtail catheter was placed into the cavity to ensure continuous irrigation. After 5-7 d, the metal stent was removed endoscopically and the necrotic cavity was entered with a therapeutic gastroscope. Endoscopic debridement was performed via the simultaneous application of a high-flow water-jet system; using a flush knife, a Dormia basket, and hot biopsy forceps. The transluminal endotherapy was repeated 2-5 times daily during the next 10 d. Supportive care included parenteral antibiotics and jejunal feeding. All patients improved dramatically and with resolution of their septic conditions; 3 patients were completely cured without any further complications or the need for surgery. One patient died from a complication of prolonged ventilation severe bilateral pneumonia, not related to the endoscopic procedure. No procedure related complications were observed. Transluminal endoscopic necrosectomy with temporary application of a self-expanding metal stent and a high-flow water-jet system shows promise for enhancing the potential of this endoscopic approach in patients with walled-off pancreatic necrosis and/or a pancreatic abscess.
authors.affiliation: Department of Gastroenterology and Endoscopy, Fejér Megyei Szent György Teaching Hospital, H-8000 Székesfehérvár, Hungary. istvan.hritz@freemail.hu
authors.forename: István
authors.initials: I
authors.lastname: Hritz
authors.forename: Roland
authors.initials: R
authors.lastname: Fejes
authors.forename: András
authors.initials: A
authors.lastname: Székely
authors.forename: Iván
authors.initials: I
authors.lastname: Székely
authors.forename: László
authors.initials: L
authors.lastname: Horváth
authors.forename: Agnes
authors.initials: A
authors.lastname: Sárkány
authors.forename: Aron
authors.initials: A
authors.lastname: Altorjay
authors.forename: László
authors.initials: L
authors.lastname: Madácsy
mesh_terms: D000368:Aged; D003131:Combined Modality Therapy; D003646:Debridement / Q000295:instrumentation*; D004106:Dilatation; D004724:Endoscopy / Q000295:instrumentation*; D004867:Equipment Design; D017809:Fatal Outcome; D005260:Female; D006801:Humans; D008297:Male; D008670:Metals; D008875:Middle Aged; D019283:Pancreatitis, Acute Necrotizing / Q000175:diagnosis / Q000601:surgery*; D011474:Prosthesis Design; D011677:Punctures; D015607:Stents; D007507:Therapeutic Irrigation / Q000295:instrumentation*; D016896:Treatment Outcome
chemical_list: D008670:Metals
keywords: Acute necrotizing pancreatitis; Endoscopic necrosectomy; Self-expanding metal stent; Walled off pancreatic necrosis; Water-jet system